Sincelejo Diaries, part 2


Sincelejo

Tuesday –  We drove back from Cartagena this morning before heading to surgery in the afternoon for a bypass grafting case.  For the first half of the way, I sat in the back and enjoyed looking out the window.  It’s amazing how dry parts of Bolivar are.

The drought has been responsible for the deaths of over 20,000 farm animals here in Colombia.  The small lakes are disappearing, from my first trip to Sincelejo to my most recent visit just a few weeks later.  The trees and bushes besides the roadways are completely coated with layers of dust from passing vehicles.  It gets greener as we pass into Sucre, but it’s a sad reminder of the devastating effects of climate change.

After stopping for breakfast along the way, where we met up with Dr. Melano, Iris went with Dr. Melano and I stayed with Dr. Barbosa.  We talked about music mostly.  At one point, a former patient from several years ago called, just to say hello.  The patient had recently heard that Dr. Barbosa now had a surgery program in Sucre. (The patient had previously traveled to Cartagena from a small town in Sucre for surgery.)

Once we got to Sincelejo, we headed to the hospital to see our patient before surgery and go over any last-minute questions or concerns.

(Of course) I was worried about finding vein but we easily found good quality conduit.  Dr. Salgua has been very nice about helping me with the saphenectomies.  The team teases me because I have a difficult time pronouncing her name.  We have a kind of system: While I finish closing the leg, she moves up the table to assist the surgeon in starting the grafts.  Then when I finish wrapping the leg, I stay at the back of the table with the instrumentadora, learning the Spanish names for all the instruments.  Once the chest is closed, she does a layer of fascia and I close the skin incision.

It’s a little crowded sometimes with the new instrumentadora learning the essentials of cardiac surgery, but the atmosphere at the back of the table is a lot different from the climate at the top.  (Dr. B is always calm, pleasant and entertaining – but Dr. Salgua is almost completely silent the whole time).  I am a lot quieter than my “out of OR self” when I am across the table from the surgeon too..

Wednesday – Another coronary case, on a fragile-ish patient (multiple co-morbidities including chronic kidney disease etc).  It was a long case and I was a little worried the whole time but the patient did well.  (I always worry about the frail patients).

I did okay too – performing a saphenectomy with Dr. Barbosa.  The patient had a vein stripping procedure previously (on one leg only) so I wanted to be sure to get a good segment of vein on the remaining vein.  I think Dr. Barbosa was worried about the quality of the conduit (because he kind of hovered – and didn’t relax until we started harvesting it.)

skip harvesting

Skip harvesting

I wish I would have more opportunities to perform a traditional saphenectomy (one very long incision).  I assisted on one several years ago – and I think if I had a chance to do a couple more, I would feel more comfortable skip harvesting.  Of course, a headlamp would also help.  (It’s kind of dark looking down the skip ‘tunnels’).  Then once I’ve mastered skip harvesting, I think it’s just another small jump to endo-harvesting with a scope.  I know a lot of people never bother learn to skip harvest, but I feel more comfortable building on the principles of open procedures first.  I might need them in an emergency case which is kind of why I wished I had more open saphenectomy experience.

Thursday – Saw three patients in the clinic today.  However, on reviewing the patient records and an intra-office echocardiogram, one of the patients definitely doesn’t need surgery at this point. (Asymptomatic with only moderate valvular disease).  We were happy to let him know he didn’t need surgery even if that means fewer cases.

Two surgeries today.  The first case was a bypass case for a patient with severe coronary disease and unstable angina.  Dr. Salgua and I did the harvest.  I think Dr. Barbosa is a little nervous about handing over the reins to me for harvest because he keeps a pretty close eye on me while I am doing it.  But then again, it might be because I am a little overly cautious and hesitant at this point.  If I didn’t have Dr. Salgua to look over my shoulder and encourage me onward, I’d put clips on everything and proceed at a snail’s pace to make sure I do it right.  But since it’s still my first week, maybe I shouldn’t be so hard on myself.

On the other hand, he must think my suturing is pretty good, because he just trusts me to do it correctly.

The second case was a patient from last week, who developed a large (symptomatic) pleural effusion and cardiac effusion (no tamponade or hemodynamic instability) which is a pretty common surgical complication.  The case proceeded well – I placed the chest tube, with Dr. Barbosa supervising.  Dr. Barbosa performed the cardiac window portion of the procedure.

Sadly, one of our patients from last week died today.  It was a fragile patient to begin with, and even though surgery proceeded well, the patient could never tolerate extubation and had to be re-intubated twice after initially doing well.  From there, the patient continued to deteriorate.

Friday

Today we had a beautiful aortic valve surgery.  This has always been one of my favorite cardiac procedures.  Somehow its elegant in the way the new valve slides down the carefully coördinated sutures.  (I don’t have pictures from this case – since I was first assisting – but I will post some from a previous case – so you can see what I mean).

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Dr. Salgua worked an overnight shift, so I was at the top of the table – (and yes, noticeably quieter than normal.)  I was surprised at how fast it seemed to go – but maybe that’s because everything went so smoothly.  Or maybe because we’ve done a lot of coronaries lately, which is a much more tedious and time-consuming process.

Iris and I are working on a patient education process – as a way to improve the continuum of care for patients (particularly after discharge).  I really enjoy working with Iris because I feel like we are always on the same page when it comes to patient care.

While it’s been a tiring week for the crew – I am, as always! exhilarated and happy to be here in Sincelejo.  Just knowing it’s the end of another week (and I am that much closer to going home) has me feeling a little sad.  But I guess I can’t stay forever, and I sure don’t want to take advantage of all the kindnesses that have been extended to me.

That being said:

At the end of every surgery, every day and every week in Sincelejo – I am grateful.  Grateful to Dr. Barbosa for being such a willing and patient teacher – grateful to the operating room crew (especially Iris Castro and Dr. Salgua) and particularly grateful to all the kind and generous patients I have met and helped take care of*.

The medical mission

This week I had another inquiry about ‘medical missions’.   I know people mean well when they ask about medical missions, or when they participate in these types of activities but…

Long time readers know my philosophy on this – don’t go overseas so you can pat yourself on the back over the ‘great deeds’ you performed ‘helping the poor’.  It’s patronizing to the destination country and its inhabitants – and generally not very useful anyway.  An awful lot of volunteers with real skills and talents go to waste on these so-called mission trips when their skills might be better served (in less exciting or glamorous ways) in free clinics in our own country.

But it does give everyone involved a chance to brag about how selfless and noble they have been; traveling thousands of miles, sleeping somewhere without 24/7 wi-fi (and who knows what other hardships).

Instead, change your orientation – and maybe challenge that assumption that everything you’ve learned about medicine, health care and taking care of people is better and superior.  Open your eyes and be willing to learn what others have to teach you instead.

* I always opt for full disclosure and transparency with the patients.  I introduce myself and explain that I am a studying with Dr. Barbosa, what my credentials and experience is to give them the opportunity to ‘opt out’.

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Iris & Ximena


Here in Cartagena, I have been fortunate enough to have two great roommates; Iris and Ximena.

Dr. Barbosa made all the arrangements for me, and I was a little nervous about bunking down with another nurse (we can be temperamental and territorial at times) but living with Iris has been absolutely wonderful.

I was kind of worried I’d be living with some young, possibly flighty nurse who might resent having a middle-age woman in her home, cramping her style.  Instead, it’s like having an instant best friend and I love it.

For starters – we have a lot in common:  we are both academically and professionally inclined.  Iris is the perfusionist for Dr. Barbosa’s cardiac surgery service and is extremely knowledgeable.

Part of the machinery that makes up Iriis' professional life: the heart-lung machine

Part of the machinery that makes up Iriis’ professional life: the heart-lung machine

(In Colombia, Perfusion is an advanced nursing degree.  Iris obtained her master’s degrees in both critical care (National University) and Perfusion at (CES.).   She is widely acknowledged as one of the best perfusionists (if not the best) in all of Colombia.   Her peers frequently consult her seeking advice for a variety of surgical circumstances.

She is the only nurse to collaborate (and be listed on the cover) of a comprehensive Colombian textbook on Cardiology.  Her name is listed along side such esteemed Colombian physicians as Pablo Guerra, Nestor Sandoval and Sergio Franco.

Cardiology textbook

She also serves as a reviewing editor of several Colombian medical journals.  Research articles are sent to Iris to review the methodology/ study design and overall quality.  Articles she rejects will not be accepted for publication.

In her free time, it’s not unusual to find her reading the latest journal articles on cardiac surgery or working on presentations for the latest meeting or international conference on perfusion.  In fact, she recently returned from the annual Colombian conference on cardiology and cardiac surgery in Medellin.  She is equally enthusiastic about all aspects of nursing and the position and rights of women (nurses) in Colombia and in medical society in general.

She is particularly outspoken against much of the machismo that dominates life here.  She is the one person I have learned to expect to never ask me the unpleasantly intrusive questions that seem to pass for almost introductory conversation here such as “Why don’t you have children?  Don’t you want them?  What does your husband think of that?  Your husband permits you to be here [in Colombia] without him?”*

Even when we don’t agree on all issues, she never judges my opinions or thoughts.  She endeavors to understand my reasoning instead.  It’s refreshing.

This combination of intellect, insight and experience makes for a lot of interesting and engaging discussions in the evenings as we relax and enjoy the fragrant breezes that bring daily relief to the sweltering city.

A strong woman in a culture of machismo

Iris is also extremely forthright and independent (traits that also resonate with me.)  She takes no ‘guff’ from anyone and lives how she pleases in a society that has a lot of difficulty accepting that (unmarried, no kids with Ximena as a part-time roommate.)

Even my professor, as charming and intelligent as he is, defaults into this kind of ‘macho’ thinking.  He tells me he worries about Iris, as “she is all alone” without a man to protect her.  He worries she is missing out on true happiness and is destined to be sad, alone.  Nothing could be further from the truth.

Rather, Iris has chosen to defy tradition, and live life on her terms.  She has friends, family and romantic attachments like anyone else.  She just maintains both her privacy and her independence despite that, sort of like Elizabeth I of England.

It is sometimes hard as an outsider to understand why this attracts some much attention – a single woman living quietly in her own apartment.  But then I think back to some of the comments I get from friends, acquaintances, co-workers and even strangers regarding locums life, and I realize, that as female professionals; whether the United States or Colombia, we still have a long way to go.

It’s just that as an American, I think I have fallen for the illusion of the possibility of female equality in way that women in other countries never have.  (The irony is that at this moment in my home country, women’s rights; to reproductive, financial and professional freedom are being eroded more that any other time in recent history.  Hard won battles of the 60’s and 70’s are being erased with nary an outcry.)

Here ‘paternalism’ rules the day – and no one pretends any different.

But there is more to Iris that a forthright, intelligent, independent individual.  She is also a nurturer, a caregiver, a nurse in the very sense of the word.

What could be more nurturing that offering up her home to an unknown stranger from another land?

“Ximena”

photo (38)

Iris and the other members of her apartment complex have adopted a white and orange stray cat that answers to a variety of affectionate terms.  One of these is “Nena”.  One my first day here, I confused “Nena” as a shortened version of Ximena, so Ximena she is.

This straggly looking, mangy little ball of fluff is adored by the residents of the small apartment building.  Typical of most cats, she is “owned”  by none, but owns each neighbor in turn.  But it was Iris who took up donations to get Ximena surgery she needed and routine veterinary care.  All the residents share in the feeding and care of the street cat – including applying a cream to her healing surgical scar, but it is Iris whom Ximena usually seeks.

While most of the residents leave their doors open during the afternoons to invite Ximena in, Ximena is most often found either inside our apartment, or bellowing outside the door (on the rare occasions that is is closed.)  She wanders in with the grace and arrogance that only a cat possesses.

She carries herself with a dignity that belies her ‘homeless’ state as to say she isn’t a vagabond but a seasoned traveler as she visits each apartment in turn – but always comes back to Iris to stay all afternoon and overnight.

Some of the neighbors our jealous of Ximena’s attention, but with our weekly journeys to Sincelejo, they always have an apportunity to host ‘Nena as their favored guest.

Iris loves to cook – and does so easily, deliciously.  She embraces a healthy lifestyle filled with daily exercise and fresh fruit and vegetables.

salad made of exotic fruits

salad made of exotic fruits

We talk about my love of Colombian food – and together one day in the kitchen, we make brevas.  She tells me with a smile that she has never made them, but used to watch her grandmother cook them for a sweet tweet.

Boiling brevas: Photo by Camila

Boiling brevas: Photo by Camila

We savor the sugary treat, one breva at a time over the next several days.

In  addition to learning how to perform saphenectomies from Dr. Barbosa, Iris is teaching me how to crochet.  My first project will be one of the small bags that is in a style typical for Colombia.  I think it is ironic that it seems easier to suture that it is to crochet.

Iris 003

But Iris is endlessly patient with me – and slowly, slowly as I unravel my mistakes and start again, I am making progress.  She has a blogspot where she showcases her latest creations.  She recently received national accreditation as a ‘native artist’ to participate in festivals and art fairs that specialize in traditional Colombia crafts.

Today, as we sit on the sofa, crocheting, we talk about plans for the Semana Santa (Easter Week).  The secretarial staff in Sincelejo has vacation plans and wants to keep the office closed all week so she can visit a boyfriend in Medellin – but Iris and I think it should remain open for the patients.  We plan to offer to staff the office, so that patients won’t have to wait a week to be seen.  We will have to navigate and negotiate carefully and diplomatically to prevent causing any hard feelings but as Iris points out, it’s the right thing to do for the patients – and the doctors, and that’s what matters. (My motives are admittedly more self-serving: more clinic = more surgery.)

*This type of questioning is fairly pervasive throughout Colombia, and is often performed as part of introductory conversation.  Once a taxi driver in Bogotá directed me to the nearest fertility clinic when I responded “No” to the question about children.  He wasn’t rude, on the contrary, he thought he was being helpful.

** Iris prefers not to have her picture taken.

The Sincelejo Diaries


 

Sincelejo from the balcony

Sincelejo from the balcony

 

Since I have very limited wi-fi while in Sincelejo, I have been keeping a diary of my time on the cardiac surgery service of Dr. Cristian Barbosa.  But then again, maybe I should explain why I am here.

I came to Colombia to learn how to perform skip harvesting saphenectomies with Dr. Barbosa.  As I mentioned previously, we’ve kept in contact since we first met, and he was gracious enough to offer to teach me.

Before I ever left Virginia, it took a lot of paperwork and diplomacy, but we were able to secure administrative permissions for me to study sapheneous vein harvesting with Dr. Barbosa at the hospital in Sincelejo.  While this isn’t medical tourism, I thought my readers might enjoy hearing about daily life as part of Dr. Barbosa’s cardiac surgery service.

 

 Cardiac Surgery in Sucre, Colombia

 

outside the operating room

outside the operating room

While the cardiac surgery program is located in Hospital Santa Maria, Dr. Barbosa and his team often travel to nearby hospitals and clinics to see new consultations.  This program is the only program in the state of Sucre and patients come from all parts of the state.

Many of the patients come from tiny pueblos of a few hundred (or thousand people).  Many others come from impoverished backgrounds.  (Colombia has a tiered health care system with a national health care plan for people from lower socio-economic classes, kind of similar to the Medicaid concept.)

We arrive in Sincelejo on Monday, March 24th in the evening.  We have a busy day tomorrow and the doctor wants to get started early (without facing the 3 hour drive in the morning.)

En Familia

In Sincelejo, we live en familia, in a large airy apartment with big windows that overlook much of Sincelejo.  There are four of us here, the surgeon, the anesthesiologist (who is Director of the program), the perfusionist and myself.  Iris and I share a large room with a private balcony.  Meals are shared and we usually travel as a group to the hospital and on errands.

After our arrival Monday evening, the doctor, the perfusionist and I head to the largest grocery store and shopping center in town.  We shop as a family, picking out fruit, arepa corn flour, coffee and other essentials.   We then head to the food court.  (They are treating me to Corral, due to my proclaimed love of Corral’s famed hamburgers).   

It sounds like it could be uncomfortable – this domestic scene with my boss and the cardiac surgery team, but surprisingly it isn’t.  Iris, the perfusionist (and my roommate both here and in Cartagena) always says they are a “cardiac surgery family,” and it feels that way – in a comforting, cozy way.

I joke and call Dr. Barbosa, “Papa” as he is the natural father figure of the group, and somehow it feels appropriate.

 

'Papa' of our cardiac surgery team

‘Papa’ of our cardiac surgery team

25 March 2014 – Tuesday

Today we travelled to Corozal to see two consultations in the intensive care unit.  Then we returned to Sincelejo to see another patient at another hospital, Maria Reina.  We eat lunch at the apartment, en familia .  Afterwards, we go back to the office to see patients before heading off to surgery.  (We had to delay surgery for several hours because the patient decided to eat breakfast.  I guess s/he was hungry too).

barbosa 081

 

Finally after this delay (to prevent anesthesia complications), we head to the operating room.  There are the typical delays while the patient is being prepped and prepared.  This gives me a chance to get to know the rest of the crew, Anita (the instrumentador or surgical tech) who runs the operating room table, Raquel, an experienced instrumentador who is training to work in the cardiac suite, and the two circulating nurses,  Patricia and Estebes.

Raquel (right) and Anita, the instrumentadors

Raquel (right) and Anita, the instrumentadors

The circulating nurses are responsible for taking care of all the duties that fall outside of the sterile field, like fetching additional supplies, medications or instruments.  They also control the environment by regulating the temperature, and adjust the electronic machinery (like the electrocautery unit, or the sternal saw) according to the surgeon’s immediate needs and specifications.

Patricia and Estebes, circulating nurses

Patricia and Estebes, circulating nurses

Dr. Salgua is the medical doctor who works in the office, seeing patients and assessing their medical (nonsurgical needs.) For the last year, she has also worked as Dr. Barbosa’s First Assistant in Surgery.  If there is any chance for friction in the operating room, most likely it will come from her.  I am cautiously nice but optimistic when I realize she is fairly quiet, and not overly aggressive.  (I relax, but just a bit.  I am still nervous about how the team will take to me, even though the common Oops! “accidental” needle stick scenario seems unlikely here.

Dr. Salgua

Dr. Salgua

 

Everyone is very friendly and welcoming and even before starting the actual surgery, I am breathing easier and starting to think that maybe I could belong here, with this group.

The surgery went well (valve replacement and annuloplasty).  After the surgery, we transport the patient to the intensive care unit and give report to the doctors and nursing waiting to assume care of the patient.

Note: patient did well and went home on POD # 3 on 3/28/2014.

 

26 March 2014 – Wednesday

More surgery today, but still no coronaries (and thus no saphenectomies).  It was a great day in the operating room – I closed the sternal incision..  (BTW, surgery went beautifully).  I am already starting to feel more at home with the operating room staff, and I feel like they don’t mind having me around.  Dr. Salgua has been very kind in assisting me during procedures, which is a relief.  She still stays pretty quiet during the cases, but I think maybe sometimes she is a bit nervous too.

 

with the team

with the team

After transferring the patient to the ICU, our second visit to the patient from yesterday finds her over in the general surgery ward.  (This morning she had been sitting up in a chair in the ICU when we arrived.)  She looks good and states she is sore, but otherwise fine.

barbosa 082

The cardiac catheterization lab calls; there are four cath films they want us to review, and patients to discuss regarding surgery.  The patients themselves are resting in the recovery area after the cath procedure, so our administrative assistant, Paola makes appointments for each of them and instructs them to bring their families, medications and any questions.

The most interesting part of the cath lab is who is doing the caths.  It’s a nurse, while the cardiologist sits behind the protective radiation shielded glass enclosure viewing the films and calling out for additional views.  I wonder if the nurse knows that in the United States, a similar position would pay over 100,000 dollars.  But this is one of the things that I see a lot of her in Colombia and in Mexico.  Well trained nurses being essentially nurse practitioners (making diagnoses, treating disease, performing invasive procedures) but without the status or the compensation.

My roommate and I talk about this disparity sometimes.  She’s a master’s trained nurse herself, so it makes for some very interesting discourse and insights. (She doesn’t like to have her picture taken, so I haven’t.)

We finish seeing patients and head home.  The doctors head off for a siesta.  Dr. Barbosa has been up since before five for his daily exercise before surgery.

As for me – after some scouting of the immediate areas around the hospital and the apartment, I went on my motorcycle tour.  It was great fun but I got an important reminder of the perils of motorcycles just a few days later.

Note: After and uneventful surgery (defect repair), patient recuperated quickly, and was discharged 3/29/2014.

 

27 March 2014 – Thurday

The week is really flying by.  I’ve been having fun with the operating room team.  They are a great group. Everyone has been extremely nice and welcoming.  (You can never be sure how your presence is going to be tolerated or change the existing dynamic.)   Dr. Melano and I have a couple of animated discussions over current practices, literature and recent meta-analyses.  It’s an enjoyable discourse even though my vocabulary often fails me.  I hear myself making grammatic mistakes and repeated errors in Spanish but it seems with some much going on (reviewing my anatomy, practicing my suture ties, assisting in the operating room and trying to keep up on my writing )- I just can’t seem to remember as much as I should in Spanish.  I inwardly cringe when I substitute ‘conocer’ for ‘saber’ yet again, but the word is out of my mouth in reply to a question before I can corect myself.

Dr. Salgua assists Dr. Barbosa

Dr. Salgua assists Dr. Barbosa

I sit out this surgery (still no coronaries) and spend some time taking pictures to document my experiences here.  I got a couple of shots that I really like, including one of Dr. Barbosa, Dr. Salgua and Raquel.

one of my favorite pictures from that day

one of my favorite pictures from that day

 Note:  Patient discharged home 3/29/2014.

28 March 2014 Friday (and coronaries!)

Today is my big day – and I am excited and a little scared too.  I got up at five this morning and went with Dr. Barbosa to the exercise park, so I would have a place to walk while he played tennis.  It helped me get ready for the day, and I got to see where Dr. Barbosa uses up all of his pent-up aggression.  He turns it into a power slam. (I don’t know tennis terms, but whatever swing he was doing – it must be responsible for his tranquil overall demeanor.)

After breakfast, we head to the hospital.  We check on our hospitalized patients before going to see today’s surgical patient in pre-op.

Our patient is a bit fragile-looking so (of course!) I worry about her and how she will do with surgery.   I also worry that I might not sew straight, now that it’s time for me to get to work.

Some of my previous OR “lessons” have been brutal, including several at a troubled facility that sent me running away from cardiac surgery (of all kinds) for several months*.  This is what fuels my anxiety.  (I am not anxious by nature).

But here in Sucre, in this OR,  this experience is nothing of the sort – Dr. Barbosa is an excellent teacher.  I don’t know why it’s a surprise.  He’s always been a bit of a  Clark Kent of the operating room; pleasant, calm and methodical.**  This is just the same.  In his soft burring voice he goes over the procedure with Dr. Salgua and I.  The he oversees our attempts, gently encouraging and coaxing.  It is yet again, a comfortable experience, instead of a traumatizing, horrible one.

a pretty great teacher

a pretty great teacher

 

I don’t have any pictures which would show my twinkling eyes which are the main indication of my happy grin beneath my mask as I finished closing the last leg incision.

We wrap the leg when we finish and move up to the ‘top’ of the operating room table.  (I’ve learned that the top and the bottom of the operating room table are two very different places.)

I close the chest incision – surgery is over.   We transfer the patient to the ICU.  She remains a little fragile but has no immediate problems.

barbosa 047

After making sure the patient is stable, the team heads over to Clinica Maria Reina.  We have received a call that a trauma patient is being placed on ECMO (to support his lungs) after developing a fat embolism.  We are standing by to help, as needed.

As I look around, and talk to the staff, I find that there are three patients in the small ICU, all young men in their twenties, all intubated with critical injuries, all due to motorcycle accidents.  One patient, just barely an adult has lost a limb as well.  He is awake and hitting the siderails with his remaining hand to capture the nurse’s attention.  She holds his hand and speaks soft to him and he calms down.  Watching this, along with the patient struggling to survive as doctors rush to connect ECMO is a sobering reminder of how devastating my joyride could have been.

The patient is connected to ECMO without incident.  As a weary unit, all four of us return home.

Cartagena 004

The view from my private dance floor..

Everyone is exhausted – but I am exhilarated!  I just want to dance – so I do, by myself, on the balcony with my phone blaring out some music.  Later that evening, we go out for dinner to celebrate a successful week.  I am still in a joyous dancing mood which probably drives my companions a little crazy but it’s been such a great day..  so when we return home, I dance some more.

March 29th, 2014 – Saturday

In the morning after my dancing spree – Dr. Barbosa and I walk down to the hospital.  Our fragile patient from yesterday is doing okay, and our other two patients are ready to go home.  I review discharge instructions with each patient, and hope that I am not mangling my Spanish too badly. But they seem to understand me, so maybe I am doing alright.  The doctor is nearby, writing prescriptions, to clarify anything I have trouble explaining.

One patient asks about getting out of a chair without using his arms (and stressing the sternal incision) so I demonstrate my favorite technique, and together we practice.

After we finish, we head back to the apartment to eat breakfast, finish packing and head back to Cartagena.  Dr. Melano is staying behind (along with Dr. Salgua, who lives in Sincelejo) to check on our remaining patient.

The ride back is pleasant, but I start to feel some of the fatigue from all of the excitement of the week.  I also feel a little sad to be leaving our little cardiac ‘family’ for a few days, which is probably crazy considering how much time we’ve all spent together.  I guess it’s because I know it’s just temporary.

Iris and I head back to ‘our’ Cartagena apartment where the neighborhood cat, Ximena is waiting for us.

Now we will relax, write and get ready for the return trip on Tuesday.

* A deliberate elbow to the face was just the beginning of a series of humiliations at a previous facility.

**Pulling on his superman cape when needed.

Start here…


This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.

Site merge


Notice of site merge:  since much of the content tends to run parallel – from medical tourism to medical information about medical conditions and treatment options – I am merging Cartagena Surgery content with Latin American surgery.

For my readers here at Latin American Surgery, this means that the tone of the blog will change with the addition of my more personal posts on photography, student life (during various internships), travels and road trips within the USA and other posts.  I hope that this give readers a better sense of the person behind the posts.

I debated for several months before initiating the large-scale move – (hundreds of posts), and it will take time to organize and arrange all of the new additions.  Hopefully, the addition of the posts is welcome to all of my long-term followers  – who can now find information on medical conditions  (aortic stenosis) and the doctors (cardiac surgeons) to treat it at the same place.

Memories of Mexicali


As I get ready to leave Mexicali, I am posting several old postcards of the city.  Today’s post is more reflective of the many changes going on now – but we’ll be back to our usual topics soon..

this one is just a few years old

I’m sure that my regular readers can tell that parting is ‘such bittersweet sorrow’.. How could it not be  – when I have met such wonderful people, learned so much and made some great friends?

Mexicali – Av..Revolucion – circa 1960’s

At the same time, I am excited about moving forward – school, studying in Bogotá, and working on my research.

Governmental Palace (now part of UABC) circa 1960’s

Hard to leave the hospital in particular.  I went back there yesterday and got to see some of the people who were so welcoming, starting on my very first day.  (When I was still struggling – particularly with the regional accent here – which differs from the Spanish I was used to hearing.)

Av. Lopez Mateos

It was great to be back in the operating room with Dr. Ochoa.  With classes in Nashville, and my homework assignments, I hadn’t seen him for a couple of weeks.

I know I will miss him most of all even if I am embarrassed to admit it.  He will always rank up there as one of the world’s great “bosses”; he was great to be around; day after day after day- which is not something you can say about most people.   I know I’ve talked about what a good (and patient!) professor he has been, but this last month, when we’ve been collaborating on the book, has changed the dynamic a bit.  He’ll still always be ‘my professor’ and a surgical colleague – but now that we have worked together in a different capacity – he is more of a friend too.  (I’ve actually called him by his first name a couple of times, which is a hard thing for me to do..)

I think, too, that is was a little-bit eye-opening for him to be more involved on the writing (and researching) side of things.  I hope he enjoyed it as much as I have.  (He should – he did all the research on Mexicali’s nightlife.. )

and Joanna – who has become one of my best friends.. (Not just my best friend in Mexicali – but someone I consider a really close friend – anytime, anywhere..)  It just seems like we connect and communicate on that level that only really close friends ever do.. Despite different backgrounds, I feel like I’ve known her my whole life..  So it’s hard to say “see you later” to Joanna.. (“See you later” is so much better than goodbye, don’t you think?)

So of course, as you can imagine – I spent my last day at the hospital – in the place I love the most: the operating room.

Dr. Rivera (left) and Dr. Ochoa

I’m going to miss my ‘movie star’ surgeon too – Dr. Rivera has been great about being in all my pictures and film clips..  He’s a nice young resident – (still grounded)  and I think he’s be a great surgeon when he finishes his training..  He’s interested in surgical oncology – so we might be writing about him again in a few years..

 

Meet Lupita Dominguez, surgical nurse


Had an amazing day yesterday – one of those days that reminds you how much we can do in medicine when we all work together.  I am hoping to write it up as a case study – if not – I will tell you more about it here.  (The patient was exceedingly gracious when I asked permission.)

But this morning, I was back in the operating room with Dr. Cuauhtemoc Vasquez.  (If he is tired of me – he sure doesn’t let on..)

I finally had the opportunity to get some of the pictures I’ve been trying to get on every visit to his OR – to show readers the heart, and the pulse of cardiac surgery..

There’s a running joke in Mexicali – if you need help in the operating room, any operating room, in any of the hospitals in the city; just holler for Lupita because she’s always there.

Introducing Lupita Dominguez, surgical nurse

All kidding aside on the popularity of the name “Lupita” among operating room personnel, there is just one Lupita that I would like to talk about today,  Lupita Dominguez, who is Dr. Vasquez’s surgical nurse.  In the months, and the numerous occasions that I have been a guest in Dr. Vasquez’s operating room, I’ve had the opportunity to observe and appreciate the hard-working Lupita.

Lupita Dominguez with Dr. Vasquez

Teacher, Coordinator and Mind-Reader

Most people don’t know it – but Lupita has the hardest job in the operating room, and probably (in Mexico) the most poorly paid.   They say a good scrub nurse has the instrument in the surgeon’s hand before he knows he needs it – and from what I’ve seen, that’s Lupita.  She’s here an hour earlier than the rest of the surgical team, getting everything ready, and she’ll be here after everyone else escorts the patient to the intensive care unit.

Here she is, a blur of motion as she takes care of everyone at the operating room table

As I watch again today, she is ‘running the table’ and anticipating the needs of not just one demanding cardiac surgeon, and an additional surgeon, but also one surgical intern, and another student.  With all of these people crowded at the table, she still has to follow the surgery, anticipate everyone’s needs and keep track of all the instruments and supplies in use.  In the midst of this maelström, the scrub nurse has to ensure that everyone else maintains sterility while preventing surgical instruments from being knocked to the floor, or otherwise misplaced (a difficult task at times).

Here she is demonstrating how to correctly load the needle, and pass sharp instruments

She’s forever in motion which has made taking the few photos of her a difficult endeavor; She’s shaving ice for cardioplegia, while listening to the circulator, adjusting the OR lights, and gently guiding the apprentices.  She’s so gentle in her teaching methods that the student doesn’t even realize she’s being led, and relaxes enough to learn.  This is no easy task, particularly since it’s just the beginning of the July, and while bright-eyed, pleasant and enthusiastic, the new surgical resident is inexperienced.  Her own student nurse, is two parts shy, but helpful enough that near the end of the case, (and the first time since I’ve known her), Lupita actually stops for a moment and flashes me a wave when she sees the camera faced in her direction.  I’m surprised, but I manage to capture it.

a very rare moment – Lupita takes a millisecond to say hello

She is endlessly busy, but ever uncomplaining – even when a scheduled surgery takes an unexpected turn and extends to twelve or even fourteen hours.  Bladder straining perhaps, baby-sitter calling, but Lupita never complains.  She’s not unique in that – scrub nurses around the world endure long hours, tired feet and legs, hungry bellies, full bladders, and aching backs as they complete their days in the operating room.  But she does it with good nature and grace.

Lupita assisting Dr. Vasquez during surgery

The surgical nurse

In the United States, this important job has been lost to nursing, a casualty of the ongoing shortage.  Positions such as scrub nurse and others like it have been frequently replaced with technicians who require less training and thus, less compensation that nurses.  Maybe the nursing profession doesn’t mourn the loss; but I do.

as you can see – here she is, ‘behind the scenes’ so to speak..

But in Mexico, and many other locations, this position remains the exclusive domain of the nurse.  Nurses such as Lupita, spend three years studying general nursing in college, before completing an (optional) additional year of training for a specialty such as the operating room.  After completing this training, these nurses spend yet another year in public service.

The idea of the public service requirement is honorable yet almost ironic (to me)  at times, since the majority of nurses in Mexico will spent their careers in public facilities, and by definition (in my mind at least), nursing is an occupation almost entirely devoted to the service and care of others.

Working conditions vary but some constants

Depending on the country, the culture, and the facility; conditions may vary; nurses may get short breaks, or be relieved during particularly long cases.   The only constant is the cold, and the hard floors, and rickety stepstools[1].  While the nurses here tell me that the workday is only seven hours long – I’ve been in the operating room with these ladies before, and watched a supposed ‘seven-hour’ day stretch to fifteen.   But it is just part of being a nurse.

[Usually I tell people when I am writing about them – but on this instance – there was never an opportunity.. but she (and all the nurses in the OR with Dr. Vasquez) certainly deserve mention.]


[1] Temperatures are set lower in cardiac surgery rooms.  Why the stepstools always seem rickety, I have no idea.